Tag Archives: MDGs

When implementing universal health coverage, context matters

This post originally appeared here.

As the WHO’s Millennium Development Goals reach their final phase, Sara Gorman reflects on what we have learned about how political, cultural and financial contexts impact the success of universal health coverage systems. 

Image Credit: Edith Soto, Flickr

In May of 2013, Margaret Chan affirmed the WHO’s commitment to achieving universal health coverage worldwide, proclaiming “universal health coverage is the single most powerful concept that public health has to offer”. For Chan, public health measures such as universal health coverage represent a key component of development work in the 21st century. As the Millennium Development Goals (MDGs) begin to wind down with their 2015 expiration date looming, the WHO has turned its attention toward the next set of goals for world health. With statistics revealing that more than 100 million are pushed into poverty each year due to excessive health care costs, it seems ever more urgent to advocate for universal health coverage, spreading the costs across entire populations.

Yet even as it is essential to embrace a global move toward universal health coverage, it is equally vital to continue asking whether there is enough evidence to show that universal health coverage really improves population health. If not, it will become important to search for ways to make universal health coverage more effective at achieving its underlying goal: improving health. Thus, questions must be asked not only about whether countries are implementing universal health coverage but also about whether this implementation seems to be working. What are the constraints to achieving better population health as a result of universal health coverage?

What is the evidence that universal health coverage improves population health?As Moreno-Serra and Smith have observed, much of the research on the relationship between healthcare financing and health outcomes has failed to take causality into account. A series of studies have demonstrated a correlation between greater pooling of health funds and increased life expectancy. Yet these correlations are not enough to suggest that this change in the structure of healthcare financing is causing an increase in life expectancy, especially in low- and middle-income countries facing a demographic transition.

More recent longitudinal studies have managed to show a causal relationship between universal health coverage and better healthRecent research in PLOS Medicine has noted the success of universal health coverage on women’s health in low- and middle-income countries, including Afghanistan, Mexico, Rwanda, and Thailand. However, the effects of universal health coverage can vary depending on the robustness of a given country’s governance. Countries with strong governance tend to benefit the most from increased health coverage, while countries with weak governance benefit much less. It therefore seems essential that health coverage expansion in countries with poor governance infrastructure be accompanied by improvements in public administration. Because the effects of universal health coverage seem prone to the influences of context, there is a need for more studies of ways in which particular small changes in local institutions and government and financial structures can affect the relationship between universal health coverage and improved population health.

Some low- and middle-income countries have faced serious setbacks in implementing universal health coverage. In Nigeria, for example, universal health coverage has largely faltered due to poor infrastructure and low-quality health services. Problems with implementing universal health coverage in Mexico are another example of poor infrastructure and efficiency before the implementation of the new plan carrying over into the new plan and reducing its potential effects on population health. A lack of health facilities in rural areas remains a major barrier for poor people who are now covered but have nowhere to go for healthcare. In addition, since the system is financed through central government allocations to states, the country has faced problems with lack of accountability and transparency regarding use of these state funds.

In theory, universal health coverage is among the most powerful tools public health has to improve population health. Yet in reality, implementing universal health coverage has to be accompanied by a wide range of other health systems strengthening approaches within a broader development framework. Attention to context is key. The structure of universal health coverage plans must be sensitive to the particulars of the government infrastructure and financial structures in place in the country in question. In addition, attending to issues of supply and quality is essential. Implementing a universal health coverage plan without insuring that there are enough quality doctors and hospitals means spending a lot of money with little chance of better health results, especially for the most disenfranchised portions of the population. Universal health coverage is no magic bullet, but it is a vital tool in improving population health in the post-MDG era.


Leave a comment

Filed under Publication

Why maternal mental health should be a priority

Post originally appeared here.

As 2015 quickly approaches, the global health community has been made increasingly aware of our progress toward Millennium Development Goals (MDGs). Some remarkable progress has indeed been made. For example, the proportion of underweight children under the age of five in developing countries has declined from 28% to 17%between 1990 and 2011. Significant progress has also been made in reducing mortality among children under the age of five. In 1990, 12 million children under five died, compared with 6.9 million children in 2011. In 2011, 2.5 million people were newly infected with HIV, representing a 24% decrease from the 3.1 million people newly infected in 2001. However, one millennium development goal has shown particularly slow progress: MDG 5, namely, improving maternal health. Few countries are on track to achieve the first part of MDG 5’s goals, reducing maternal morality by 75%. Sub-Saharan Africa is in the most dire position, with a regional maternal mortality rate of 640 maternal deaths out of 100,000 live births, and a decline rate of merely 0.1%. In the summer of 2012, the University of Cambridge hosted a conference on the topic of “New Approaches to Maternal Mortality,” recognizing the crucial need to address the question of what is going on with global maternal mortality rates and to begin to address potential solutions.

While numerous factors are still converging to produce this grim picture, one key element is often missing from the discussion: improving maternal mental health. Working toward solutions to mental health problems that plague new mothers in a wide variety of settings, including in developing countries, could go a long way in improving both maternal and child health. Integrating mental health programs with maternal health programs is not only as important in saving mothers’ lives as screening for malaria and treating HIV in pregnant women but it could also prove essential in achieving two distinct but interrelated Millennium Development Goals: improving maternal health and reducing the number of deaths in children under the age of 5.

A recent article in PLOS Medicine delineates some reasons why maternal mental health is not a high priority on maternal health agendas. For one thing, a number of myths prevail that make maternal mental health seem irrelevant or unimportant in comparison to other threats facing maternal health. One especially troubling myth is the notion that maternal mental health problems are rare in developing countries, where maternal deaths represent a more significant problem than in the developed world. The authors note that this perception is misguided and cite evidence that rates of perinatal depression in low- and middle-income countries are actually higher than in high-income countries, ranging from 18% to 25%. Another misperception involves the idea that maternal depression is only tangential to maternal health. There is a conception that obstetric complications and infectious diseases represent much more immediate threats to maternal health than mental health issues. Yet this notion turns out not to be entirely true. Maternal depression certainly contributes in a very direct and striking manner to poor outcomes in infants. Maternal depression has been associated with pre-term birth, low birthweight, undernutrition, and higher rates of diarrheal disease. Suicide is actually a leading contributor to maternal mortality worldwide, and suicidal thoughts and tendencies occur in up to 20% of mothers in low- and middle-income mothers, in comparison with 5 to 14% of mothers in high-income countries.

Part of the problem with treating maternal depression is that it can be difficult to detect, especially in resource-poor countries. Core symptoms of depression such as fatigue and poor sleep are also effects of motherhood and often go unnoticed in new mothers. Screening for depression should be an integral component of antenatal visits and health care professionals who do not specialize in mental health should be trained to recognize symptoms of depression in pregnant women and new mothers. Over the last decade, interventions by non-mental health specialists have produced promising results, and efforts are being expanded to low- and middle-income countries with encouraging outcomes. ThePerinatal Mental Health Project (PHMP), based at the Mowbray Maternity Hospital in South Africa, included screening by midwives of all women in antenatal care for mental health problems and referrals for counseling and psychiatric care if necessary. The intervention resulted in high coverage (90%) and uptake (95%) of PMHP screening, and staff responsible for the screening expressed relief, rather than a feeling of burden, about the integration of maternal and mental health systems in order to address a previously unmet need.

International donors and stakeholders should be made aware of the dire effects of maternal depression on maternal and child health and should be encouraged to provide funds and aid specifically for maternal mental health. In particular, the evidence for the effects of mental health on physical health should be emphasized in communication with international donors. In addition, donors should be made aware that integrating mental health services into existing treatment platforms could prove an important opportunity to leverage resources efficiently, a major current preoccupation of the global health community.

If the Millennium Development Goals are to be achieved, the international health community needs to stop viewing them in isolation from each other and recognize that many of them are intertwined and require integrated interventions. At the same time, holistic views of both health systems and individual health are vital. Strengthening across health systems, which includes strengthening local mental health services, will bring us closer to achieving the MDGs. In a similar manner, viewing individual health holistically, as the combined effect of the health of various systems, including not only the body but also the mind, will help ensure that we pay due attention to a wider variety of factors contributing to poor health worldwide.

1 Comment

Filed under Publication